While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?
Palpate for pedal pulses.
Turn the patient every three hours.
Document the stage 1 pressure injury.
Elevate bilateral heels.
The Correct Answer is A
A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.
B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.
C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.
D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Green, soft stool after the patient received antibiotics: Green stool can be a side effect of antibiotics due to changes in gut flora but is not typically concerning.
B. Large, loose stool after the patient received a laxative: This is an expected outcome of laxative use and is not cause for concern.
C. Dry, hard stool from a patient receiving opiates: Opiates commonly cause constipation. While this requires management, it is not the most concerning finding.
D. Black tarry stool from a patient receiving an anticoagulant: Black tarry stool (melena) indicates gastrointestinal bleeding, which can be life-threatening, especially in a patient on anticoagulants. Immediate assessment is required.
Correct Answer is C
Explanation
A. Take the report home and keep it locked up: Incident reports are confidential legal documents that must remain within the healthcare facility per policy.
B. Place the report in the client's medical record: Incident reports should not be included in the client’s medical record to prevent liability issues. Instead, objective documentation of the event and any interventions should be recorded in the chart.
C. Maintain the report according to agency policy: The report must be handled per facility protocols, typically submitted to the risk management department to improve patient safety.
D. Email the report to their nursing supervisor: Incident reports contain sensitive information and should be submitted securely following facility policy, not via email.
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